Vectored Infectious Diseases: Malaria in Ethiopia

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| A A y y n n a a l l e e m m A A d d u u g g n n a a , , J J u u l l y y 2 2 0 0 1 1 4 4 w w w w w w . . E E t t h h i i o o D D e e m m o o g g r r a a p p h h y y A A n n d d H H e e a a l l t t h h . . O O r r g g LESSON 13 Vectored Infectious Diseases: Malaria in Ethiopia

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LESSON

13

Vectored Infectious Diseases: Malaria in Ethiopia

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Malaria

Introduction

Ethiopia’s fight against Malaria started more than half a century ago. “Initially malaria control

began as pilot control project in the 1950’s and then it was launched as a national eradication

campaign in the 60’s followed by a control strategy in the 70’s”. “In 1976 the vertical

organization known as the National Organization for the Control of Malaria and Other Vector-

borne Diseases (NOCMVD) evolved from the Malaria Eradication Service (MES)” [1]. The

effort has seen alternating periods of successes and failures. As is the case in all places where

malaria is endemic, the disease is far from being conquered. The agent – plasmodium – has

developed resistance to a number of drugs and the vector mosquito has developed resistance to

drug chemicals used to kill it. The early 21st century fight in Ethiopia was guided by the Abuja

(Nigeria) declaration with the following targets for the year 2005 [2]:

At least 60% of children affected by malaria should have access to rapid, adequate and affordable treatment,

At least 60% of those at risk, especially pregnant women and children under five, should benefit from the most

appropriate combinations of personal and communal protection, including insecticide treated nets (ITNs),

Malaria

Fractors in Malaria Transmission:

Climate, Physiography,

Economic Activity

Prevention and

Treatment

Disease Burden

Socio-Economic

Factors

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At least 60% of pregnant women at risk, especially those at first pregnancy, should have access to intermittent preventive treatment.

It is estimated that three-fourths of the land below 2000 meters in Ethiopia is malarious with

two-thirds of the country’s population at risk. [2]. This makes malaria the number one health

problem in Ethiopia with an average of 5 million cases a year [3] and 9.5 million cases each year

between 2001-and 2005 [4]. The disease causes 70,000 deaths annually and accounted for 17%

of outpatient visits. It also accounted for “…15% of admissions and 29% of inpatient deaths” -

but these figures considered to be low given that more than a third of the country’s population

does not have access to health services and cases go unreported [4]. A number of contributing

factors have been identified to explain the high incidence and prevalence rates of malaria in

Ethiopia:

The burden of malaria has been increasing due to a combination of large population movements, increasing large-

scale epidemics, mixed infections of Plasmodium vivax and P. falciparum, increasing parasite resistance to malaria

drugs, vector resistance to insecticides, low coverage of malaria prevention services, and general poverty. Outpatient

consultations, inpatient admissions and all in-patient deaths have risen by 21-23% over the last five years.

…Ethiopian adults, unlike their counterparts in more endemic areas, have relatively little protective immunity and are

also vulnerable to malaria. …Epidemics, which traditionally occur every five to eight years, are a hallmark of malaria

in Ethiopia. The epidemic of 1950 is estimated to have caused 3 million cases and resulted in 150,000 deaths.

Unstable and largely unpredictable malaria epidemiology makes surveillance, information management and logistics

for vector control and pharmaceuticals of paramount importance… Plasmodium vivax and Plasmodium falciparum

comprise 40% and 60% of malaria infections respectively [4]

Malaria (on the negative side) and the timely arrival of rainfall (on the positive side) are among

the most crucial determinants of economic performance in Ethiopia with GDP growth rising and

falling in Ethiopia in the aftermath of a rise or fall in rainfall amounts and the severity of malaria

transmissions. The Ministry of Health has summarized the impact of malaria in Ethiopia as

follows:

"The socioeconomic burden resulting from malaria is immense: 1) the high morbidity and mortality rate in the adult

population significantly reduces production activities; 2) the prevalence of malaria in many productive parts of the

country prevents the movement and settlement of people in resource-rich low-lying river valleys; on the flip side, the

concentration of population in non-malaria risk highland areas has resulted in a massive environmental and

ecological degradation and loss of productivity, exposing a large population of the country to repeated droughts,

famine and overall abject poverty; 3) the increased school absenteeism during malaria epidemics significantly

reduces learning capacity of students; 4) coping with malaria epidemics overwhelms the capacity of the health

services in Ethiopia, and thus substantially increases public health expenditures." (cited in [3])

Malaria shows a strong seasonal pattern “…with a lag time varying from a few weeks at the

beginning of the rainy season to more than a month at the end of the rainy season” [3].

Government actions and international assistance are helping to make a difference under the “roll

back malaria” (RBM) banner. The current operational plan, also known as “the [US] President’s

Malaria Initiative (PMI)” is assisted by and seeks to build on the United States Government’s

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“… $1.2 billion initiative to rapidly scale up malaria prevention and treatment interventions in high-

burden countries in sub-Saharan Africa”. The goal of the US initiative is [4]:

“… to reduce malaria-related mortality by 50% after three years of full implementation in each country. This will be

achieved by reaching 85% coverage of the most vulnerable groups, children under five years of age, pregnant

women, and people living with HIV/AIDS, incorporating proven preventive and therapeutic interventions, including

artemisinin-based combination therapies (ACTs), insecticide-treated bed nets (ITNs), intermittent preventive

treatment of pregnant women (IPTp), and indoor residual spraying (IRS).

The Ethiopian President’s Initiative (PMI) has a regional focus with priority given to the most

populous regions including Oromiya where three-quarters of the administrative Weredas (242

out of 261) and 3932 Kebebles out of 6107 are considered malarious. Seventeen million people

are at risk in Oromiya with annual clinical cases numbering between 1.5 and 2million. This

accounts for 20 – 35% of outpatient visits, and 16% of hospital admissions in the region where

18-30% of annual deaths are caused by malaria. [4] While the focus is on Oromiya the initiative

has a larger national goal. Twenty million long-lasting insecticide-treated bed nets - LLINs have

been distributed to 10 million households (two per household) nationwide with support from

Global Fund to Fight AIDS, Tuberculosis and Malaria - GFATM. Of these, 6.5 million were

distributed in Oromiya. The proposed fiscal year 2008 PMI budget for Ethiopia is $20 million”. [4]

National Goals and Targets of the P(US) resident’s Malaria Initiative Adapted to the

Ethiopian Reality [4].

The primary objective is to reduce malaria mortality in Ethiopia by 50% by the end of a

three-year project period. This is to be achieved through the following planned actions:

90% of households with a pregnant women and/or children under-five will own at least

one insecticide treated net (ITN);

85% of children under-five will have slept under an ITN the previous night;

85% of pregnant women will have slept under an ITN the previous night;

85% of dwellings in geographic areas targeted for indoor residual spreading (IRS) will

have been sprayed;

85% of pregnant women and children under five will have slept under an ITN the

previous night or in a house that has been sprayed with IRS in the last 6 months;

85% of government health facilities have Artemisinine-based Combination Therapy -

ACTs - available for treatment of uncomplicated malaria and

85% of children under five with suspected malaria will have received treatment with an

antimalarial drug in accordance with national malaria treatment policies within 24 hours

of onset of their symptoms.

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Malaria Ecology: General

Malaria has been a perennial cause of human suffering and mortality for millennia. The Greeks

were the first to write about it, and Egyptian hieroglyphs also made a mention of it. It exists

throughout much of “…tropical and sub-tropical regions of Africa, Asia, and South and Central

America.” [5]. A World Health Organization report routinely puts the number of yearly

infections at about 300 million and malaria mortality at 2 million a year.

Over 400 species of the malarial parasites (Plasmodium spp.) are said to exist. Many infect a

wide variety of cold-and-warm-blooded animals. Only four routinely infect humans. Malaria is

transmitted from one person to another by the bite of an infected female Anopheles spp.

mosquito.

It follows then, that ecological alterations favoring the spread of these insects also facilitate the spread of the

infection wherever malaria occurs. To get some idea of the complexity of the ecological differences among the

numerous malaria endemic zones, one must consider at least four different, yet related, aspects: the host, the insect

vectors, the parasites, and the physical conditions under which transmission occurs. Integration of these seemingly

disparate subject areas into a unified view with respect to geographic locale is essential to begin identifying

environmental factors that might be taken advantage of for the purpose of controlling the spread of the parasite.

[5]

Plasmodia: The Parasite

Malaria is caused by a protozoan belonging to the genus Plasmodium. Four species: Plasmodium

falciparum, P. vivax, P. ovale, and P. malariae infect humans but they each differ in many

aspects of their biology and geographic distribution. “P. falciparum is found in most tropical

regions throughout the world, and is the most dangerous of the four in terms of both lethality and

morbidity." All undergo two forms of replication: sexual and asexual. The, parasites develop

optimally in the vector but cease developing at temperatures 16°C or below. “High humidity

prolongs the life of the vector and transmission is extended under these conditions. In the human

intermediate host, the parasite must function at 37°C or higher, since the infection induces a

significant rise in core temperature during the height of the infection.” [5]

Anopheles mosquito: The Vector

Changes in the environment of the mosquito habitat, such as those taking place in Ethiopia,

whether natural or man-made, “… rearranges the ecological landscape in which these vectors

breed”. Every Anopheles spp. occupies a specific “….ecological niche that is genetically

determined”. Changes in temperature, humidity, altitude, population density of humans, and

deforestation are just a few ecological factors that play essential roles in the transmission of

malaria. [5].

Temperature and humidity have a direct effect on the longevity of the mosquito. Each species can thrive at an

optimal level as a result of ecological adaptation. The spread of malaria requires that conditions are favorable for

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the survival of both the mosquito and the parasite. Temperatures from approximately 21°-32°C and a relative

humidity of at least 60% are most conducive for maintenance of transmission. [5]

In tropical regions temperature and humidity are often mediated by altitude.

Altitude is significant in determining the distribution of malaria and its seasonal impact on many regions of the

world. In Africa, for example, altitudes above 1,000-1,500 m are considered safe from malaria. However, it must be

cautioned that with continuing global climate change, these figures may change, extending the range of mosquitoes

well above those altitudes as ambient temperatures rise.

The mosquito density (number of female mosquitoes per human inhabitants) is a critical

determinant of the intensity of infection. Transmission is directly proportional to density.

Mosquito longevity is also a critical factor.

The malaria vector requires water to complete its life cycle – from egg to larva to pupa, and

finally an adult mosquito. “While between 200-1000 eggs can be laid, the quantity is influenced

by the amount of blood taken in”. Blood-feeding usually starts at dusk and continues until dawn.

[5].

How does the mosquito vector find the human host?

Mosquitoes possess a highly developed set of host-detection organs that they use to sense color, light, touch, and

temperature, as well as the presence of CO2. They use all of these sensory inputs to locate a host. When a mosquito

has found an appropriate host on which to feed, it uses its two pairs of mandibles and maxillae to penetrate the skin

of the animal and pierce a capillary vessel, allowing easy access to blood. It injects numerous biologically active

compounds that cause the vessels to dilate blood to flow without coagulation, and to prevent the host from

detecting her presence.

Ecological disturbances due to human actions such as deforestation and establishment of new

settlements in previously unsettled areas “…allow for the proliferation of mosquitoes that prefer

human habitation to natural settings” as does the construction of dams.

“The breeding sites of infected mosquitoes vary greatly with regards to species. Some prefer clear water, inhabiting

the edges of streams, while others thrive in irrigation ditches and reservoirs. Some species require extensive

vegetative cover, preferring swamps and other permanent bodies of water laden with dissolved organic matter.

Mosquito breeding sites are found anywhere fresh water collects. In fact, there is a direct correlation between the

availability of water and the frequency in which mosquitoes feed on humans. Permanent natural bodies of water,

such as swamps, serve as unique breeding grounds. Construction of water control projects can also lead to shifts in

vector mosquito populations. Reservoirs, irrigation canals, and dams are closely associated with the increase of a

variety of parasitic diseases that are water dependent. Throughout the world, especially in developing countries,

dams and other related water projects continue to be planned, constructed, and operated to meet human needs such

as drinking water, energy generation, and agricultural production. For most countries, dams are a crucial part of

economic and social development, and represent a double-edged sword. The potential for dams to alleviate poverty

significantly contributes to the enhancement of human health, and simultaneously increases the likelihood of

human infection due to schistosomiasis, malaria, dysentery, and river blindness. During the construction of dams

and canals, excavation pits provide temporary breeding sites for mosquitos.” [5]

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A study in Tigray investigating the possible impacts of small dams on malaria transmission

found an unmistakable link. The rate of infection among children near dams was seven times

greater than in communities with no dams. The study, thus, concluded that “….microdams close

to villages have the potential to increase the incidence of malaria substantially among children

living nearby”. [6].

Malaria’s Disease Burden in Ethiopia

Malaria transmission peaks bi-annually from September to December and April to May [7]

coinciding with major harvesting season. Such a coincidence has serious consequences for the

subsistence Economy of Ethiopia’s countryside and for the nation as a whole. In addition, major

epidemics occur every five to eight years with focal epidemics as the commonest form. Figure

14.1 is based on confirmed malaria cases; cases that have come to the attention of health workers

and institutions. Overall infection levels estimated at about 5 million a year [8] and incidence of

malaria is not only high but rising.

Approximately 4-5 million cases of malaria are reported annually in Ethiopia and the disease is prevalent in 75

per cent of the country, putting over 50 million people at risk. Malaria accounts for seven per cent of outpatient

visits and represents the largest single cause of morbidity. It is estimated that only 20 per cent of children under

five years of age that contract malaria are treated at existing health facilities. Below are feature stories related to

malaria. [8]

Fig. 14.1 Annual (Confirmed) Malaria Cases (thousands) 1990 – 2006

Source: [7]

800

920 830

600

1030 1100 1080

1310 1385

1550

1180

1050 1100

1215

1510

1395

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ETHIOPIA: KEY MALARIA FACTS [9]

Estimated population living in malaria-prone areas: 50 million

Estimated annual malaria cases: 5 million

Additional malaria cases in an epidemic year: 6 million

Number of people dying in a 9-month malaria epidemic (e.g. 2003):114,000

Estimated number of lives saved if all malaria control interventions fully implemented

(Child survival strategy, 2005): 70,400 per year

Number of ITNs distributed to households since 2005: 4.5 million

Total number ITNs needed to reach 100% coverage: 20 million

Coartem doses distributed in public health system: 5.6 million

Malaria Rapid Diagnostic Test (RDT) kits distributed: 2.2 million

There is a low risk of malarial infection at altitudes above 2000 meters - mostly the Northern and

Eastern Highlands. This population above this elevation is in the“negligible risk” category

(Figure 14.3) and in the “malaria free” section of Figure 14.2. Regionally, Figure 14.2 shows that

all of Gambella in the worst case category – “endemic/severe” –as are most parts of

Benishangul-Gumuz. The lower elevations of the Northern and Eastern Highlands are also

shown as “endemic/severe”.

The western, central and eastern highlands, as well as the highland-fringe areas along the Rift Valley are

especially vulnerable to epidemics. In all, more than half of the population lives in epidemic-prone areas.

Epidemics seem to be intensifying and becoming more widespread. It is estimated that 48 epidemic episodes

occurred between 1986 and 1993, with severe outbreaks occurring in 1988, 1991, 1992, 1998, 2003, 2004 and

2005. [4]

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Fig. 14.2 Areas of Ethiopia by Malaria Risk Category

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The Dega zone of Ethiopia (altitude above 2,500 meters) with a mean annual temperature of 10-

15 degree Celsius is malaria-free. Much of the Woina Dega zone (Altitude 1500 – 2500 meters)

is also malaria free, especially the zone in the 2000 – 2500 meters above sea level. Malaria in

Ethiopia “…often occurs below 2000 meters, with short-lived transmission following the rains.

However, malaria epidemics have been recorded up to 2400 meters during periods when

increased temperature and adequate precipitation are conducive for both vector survival and

parasite development within the vector” [11]

Fig. 14.2 Percentage of the Population by Level of Malaria Risk

Source: Based on [10]

Percentages are also derived based on the type of malaria parasite involved. “P. falciparum

accounts for 60% of infections and P. vivax for the remainder” [11]. These are transmitted

mainly by the vector mosquito A. arabiensis. “Forty-two Anopheles species have been recorded,

with distribution varying by altitudinal zone and microhabitats…While most species are

confined to relatively small geographic areas, the four malaria vectors (A. arabiensis…A.

pharoensis, A funestus, A. nili) are widely distributed” [11]

Figure 14.4 shows age breakdowns for the most recent reporting year published by WHO for

Ethiopia.

27

34

39 Negligible Risk

Epidemic Risk

Endemic Risk

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Fig. 14.4 Percentage of Clinical Malaria Cases Reported in 2001 by Age Group and

Pregnancy Status.

Source: [10]

The Role of Human Factors in the Spread of Malaria in Ethiopia

The human factors contributing to the spread of malaria include population mobility,

urbanization, water development schemes, agricultural development schemes, conflicts, and

improper use of drugs and emerging drug-resistant malaria parasites.

“Following the end of the civil-war in 1991, significant challenges to malaria control resulted from repatriation of

large numbers of displaced Ethiopians from Sudan and settlement of demilitarized personnel…Seasonal migration

from highlands to lowlands for agriculture work has increased since 1991 with the growth of large-scale

agricultural development projects. Western lowland district populations have increased by 20-30% with the arrival

of tens of thousands of agricultural workers during the harvest season, which is also the high transmission season

for malaria…Laborers often work during the cooler evening hours when vector-biting rates are high, and often

sleep in the fields…Land scarcity in the highlands resulted in establishment of new villages for settlement in

western malarious lowlands”[11]

The low level of urbanization in Ethiopia (16%) masks recent trends of substantial increases in

urban growth rates. The chapter on migration and urbanization showed hundreds of localities

with a growth rate of 6% or higher (twice the national rate of population growth).

22%

75%

3%

Age: Under 5 Age: 5 and above Pregnant women

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“A plethora of man-made breeding sites exist in urban areas and include construction of borrow pits and brick-

making pools, garbage dumps, old tires, and discarded containers in household and office compounds…Urban

areas have also traditionally not been included in spray operations or bed-net distribution programs because of

resource constraints and the good access of urban dwellers to health institutions. When favorable climatic

conditions for transmission exist, the high urban population density, the presence of multiple breeding sites, the

lack of indoor residual spray, and lower household bed-net coverage, allow for rapid spread of malaria.” [11]

Recurrent drought has shaped much of Ethiopia’s recent economic history. Among the strategies

embarked on by the country’s government is a shift away from rain-fed agriculture to “…small-

scale irrigation agriculture through run-off harvesting in microdams and ponds” [11]. Large-scale

irrigation agriculture has also been in existence for decades as is the practice of damming rivers

for the production of hydro electric power. None of these have been without health

consequences, however, and the toll in malaria illnesses and death has been documented [12]. As

is the case in other tropical countries, river-fed agriculture has led to the resurgence of malaria

even in areas where its threats have been receding. What is good for crops like cotton and sugar

cane – high temperature and plenty of water – is also a heaven for the malaria vector. The Awash

River Valley is the most developed in terms of irrigation agriculture. “The relation between

irrigated crops and the presence of malaria has long been noted in the Awash Valley plantations

of sugarcane, fruit, and cotton…and the introduction of irrigated rice cultivation in parts of

Gambella has been suggested as an important contributing factor in malaria transmission” [11]

The low educational level of malaria sufferers most of whom live in the countryside and have

never been to school leads to failure to adhere to drug regimens or to premature stoppage of upon

a mistaken sense of early return to full health. As is the case elsewhere where malaria is endemic

drug-resistance has been the inevitable outcome in many parts of Ethiopia. There is no national

study on drug resistance in Ethiopia but isolated studies have shown drug resistance to SP to be

less than 5% in Humera and as high as 18% in Zway (1998), and even higher in another study of

Zway (30%) conducted by the Institute of Pathology in 2000 [13].

There are drug-resistance monitoring sites in Ethiopia [13] keeping records of the use/misuse of

antimalarials such as SP (Sulfadoxine-Pyrimethamine). Other anti malaria drugs in Ethiopia to

which the parasite has developed resistance includes AL (Artemether-Lumefantrine). In a related

study, the authors Tedros Adhanom et. al [11] have warn that “the high resistance level of P.

falciparum to the relatively cheap SP warrants … an immediate review…” and suggested that

“safe and effective alternative ACTs [Artemisinine-based Combination Therapy] such as AL

should be incorporated into the treatment guideline as early as possible”

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The Socio-Economic Impacts of Malaria in Ethiopia.

Up to 2 million people die of malaria around the world annually (mostly in Africa) and half of

them are children. The overall cost of malaria in Africa is summarized as follows [14]:

An estimated 300 million cases of acute malaria occur each year globally.

o 90 percent of the 2 million malaria deaths occur in Africa, mostly in young

children and especially in sub-Saharan Africa.

Malaria is the leading cause of mortality in African children under-five.

The deadliest form of the malaria parasite, Plasmodium falciparum, is most commonly

found in Africa.

The economic cost of malaria is estimated to be more than $12 billion a year in lost

productivity.

Throughout Africa, resistance to chloroquine, the cheapest and most widely used

antimalarial drug, is common.

Sulfadoxine-pyrimethamine (SP), often seen as the first and least expensive alternative

to chloroquine is also among drugs to which resistance has developed, especially in East

and Southern Africa.

ITNs around sleeping areas may reduce malarial deaths in young children by an average

of 20 percent. But the nets are expensive for the families most at-risk of malaria, who are

among the poorest in the world.

The World Health Organization (WHO) has recently backed a new, limited time policy to

spray DDT inside homes.

Studies commonly refer to malaria as “…the number one health problem in Ethiopia” [15]. The

disease is ranked as the leading communicable disease in Ethiopia “… accounting for

approximately 30% of the overall Disability Adjusted Life Years (DALYs) lost” and causes

about 70,000 deaths each year [4]. It is estimated that over five million episodes of malaria occur

each year in Ethiopia [11].

“The burden of malaria has been increasing due to a combination of large population movements, increasing large-

scale epidemics, mixed infections of Plasmodium vivax and P. falciparum, increasing parasite resistance to malaria

drugs, vector resistance to insecticides, low coverage of malaria prevention services, and general poverty. Outpatient

consultations, inpatient admissions and all in-patient deaths have risen by 21-23% over the last five years. Overall,

malaria accounts for approximately 17% of outpatient consultations, 15% of admissions and 29% of in-patient

deaths. However, as 36% of the population is out of reach of the health service coverage, these figures may under-

represent the true situation.” [4]

Quantification of the socioeconomic burden of malaria in Ethiopia is problematic since the

victims live mostly in rural areas out of sight and out of mind, but some estimates abound:

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“The social and economic consequences of the disease are sobering, with a large number of people kept from work

by debilitating illness resulting in low productivity… While household malaria burden is likely to be underestimated

by institution data, routine health reports clearly reveal the burden of Malaria on the health system. According to

annual national health indicator reports, malaria has consistently ranked in the top 10 causes of outpatient visits,

admissions, and death at health centers and hospitals for the past seven years” [11]

The Ministry of Health (quoted in [15]) summarized Malaria’s socio-economic impacts in

Ethiopia as follows:

The high morbidity and mortality rate in the adult population significantly reduces

production activities;

The prevalence of malaria in many productive parts of the country prevents the

movement and settlement of people in resource-rich low-lying river valleys. On the flip

side, the concentration of population in non-malaria risk highland areas has resulted in a

massive environmental and ecological degradation and loss of productivity, exposing a

large population of the country to repeated droughts, famine and poverty;

The increased school absenteeism during malaria epidemics significantly reduces the

learning potentials of students;

Coping with malaria epidemics overwhelms the capacity of health services in Ethiopia to

focus on other diseases, and thus substantially increases public health expenditures.

The facts outlined above make malaria in Ethiopia not just a health issue but a food-security and

environmental issue as well. The malaria season coincides with peak economic activity in rural

Ethiopia when both rainfall levels and temperature are high and conducive for the growing of

subsistence crops. Vector activity peaks in periods often set aside for cultivation, weeding,

harvesting and winnowing. Weddings and other culturally important activities also peak at this

time. In other words, optimal climatic regimes for socio-economic activities in rural Ethiopia

also favor the reproduction, propagation, and intensified vector activities. In a study by Gabriel

Senay and James Verdin’s [15] the link between temperature/rainfall on the one hand and

infection rates on the other was strong They show that infection rates have been increasing

sharply in recent years. This could be attributed partly to better reporting of cases due to

increased accessibility to health centers and larger institutions catering to the needs of malaria

patients.

Are Current Prevention and Control Strategies Succeeding?

Figures published by the Government of Ethiopia suggest considerable gains in its ongoing

efforts to tame malaria and lessen the impacts of the disease on society, health, and economy.

The following are among the main policy goals and achievements reported [16]:

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Technical Elements and Strategic Approaches:

Guided focus on early diagnosis and effective treatment

Persistent efforts in vector control

Easy and universal accessibility to ITNs

Residual periodic spray of dwellings

Other vector control methods;

o Environmental management,

o Larviciding etc

Continued efforts in epidemic prevention

Supporting Strategies:

Man-power: trained human resource development

R &D Focus on operational research and development

Expanded use of information technologies, education, and communication

Effective and permanent program monitoring and evaluation

Vision, Mission, and Goals

• Vision:

– Roll Back Malaria: The vision of malaria prevention and control in Ethiopia is to achieve and

maintain an environment in which malaria ceases to be a significant public health problem and

an obstacle to socio-economic development.

• Mission:

– The mission of the Federal Ministry of Health (FMOH) Malaria Prevention and Control

program is:

“– to expand and maintain high quality service for malaria prevention and control with special

emphasis on ensuring access to early and equitable services for the population at risk of malaria

with special emphasis to the most vulnerable population groups.”

Goals

• To contribute to MDGs Goal 6 Target 8 by reducing the overall burden of malaria (mortality

and morbidity) by 50 percent by the year 2010, compared to the baseline level (2005),

• To contribute to the reduction of child mortality (MDG Goal 4) and enhanced maternal health

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Impact Objectives

• By 2010:

• Reduce morbidity attributable to malaria from 22 percent to 10 percent

• Reduce malaria case-fatality rate in under-5 children from 5.2 percent to 2 percent

• Reduce case-fatality rate of malaria in age groups 5 years and above from 4.5 percent to 2

percent

Specific Objectives

• Achieve a full (100 percent) access to effective and affordable treatment for malaria by the end

of 2008

• Attain a full (100 percent) coverage in ITNs (insecticide treated nets) targeted districts with two

ITNs per household by 2007, (Polygamous family considered as different families)

• Achieve a 60% coverage of villages targeted for Indoor Residual Spraying (IRS) by the end of

2010 as compared to the 25% coverage in 2005,

• Detect and contain 80% of the malaria epidemics within two weeks from onset by 2010 as

compared to 31% in 2005.” [16]

Achievements so far: Vector Control/ITNs

Vector Control: ITNs/LLINs (Long-Lasting Insecticide-treated bed net)

18.2 million ITNs/LLIN have been distributed to users so far

5,108,168 nets have been procured or in pipeline

coverage of 88% at 2 ITNs/LLIN per household

Challenges and constraints: ITNs

• Insufficient knowledge of ITN usage which requires changes in community life-styles

• Lack of national (large scale) studies/surveys on ITNs utilization

• Shortage of skilled health workers (HW) for the national malaria control program (at regional

and district levels)

• The government needs to remove taxes and tariffs completely.

• Better design and customization of ITN colors and shapes

• Maintaining a high level of LLIN coverage through timely replacement of damaged or worn-

out LLINs.

• Establish a user-response system for LINs efficacy- by eliciting comments from the general

public.

• Undertake a though analysis of mosquito behavior (e.g. whether or not it is an early biter) and

its sleeping behavior

• The malaria control program is labor intensive and requires specialized equipment

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• Replastering of walls reduces the potency of spray drugs

• In places where vectors feed and rest outdoors, spraying is often ineffective

• Extra commitments resulting from overlap between IRS and ITNs distribution

• Overall shortage of operational budget

• Unresolved shortage of supplies (chemicals spray pumps and spare parts)

• Sustainability of spraying in question due to inadequacy of resources

Figure 14.6 Number of Households at the Risk of Malaria Infection and Number of

Insecticide Treated Nets (ITNs) by Region.

Source: Based on [16]

Tigray Afar Amhara Oromia SNNPR Somali Gambella Benishan

gul G. Harari

Dire Dawa

No. ITNs 608114 271744 2980168 3356227 1883662 759294 48079 114588 18955 30682

No. Households 888573 505096 5192398 5827599 3889237 1166069 197900 240600 69089 137314

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References:

1. http://alliancerpss.org/countries/eth/areas/cds/malaria/en/index1.html

2. Kassahun Negash. Ethiopia Roll Back Malaria Consultative Mission: Essential Actions to Support the

Attainment of the Abuja Targets. Ethiopia RBM Country Consultative Mission Final Report. 2004.

3. Gabriel Senay and James Verdin. Developing a Malaria Earky Warning System for Ethiopia. National

Center for EROS. Twenty Fifths Annual ESRI International User Conference. Paper No.UC2409. San

Diego, 2005.

4. President’s Malaria Initiative. Malaria Operational Plan (MOP) Ethiopia. FY 2008.

5. http://www.medicalecology.org/diseases/malaria/print_malaria.htm#sect5.2

6. http://bmj.bmjjournals.com/cgi/content/full/319/7211/663

7. http://camethiopia.org

8. http://www.unicef.org/ethiopia/reallives_386.html

9. http://www.unicef.org/ethiopia/malaria.html 10. http://www.afro.who.int/malaria/country-profile/ethiopia.pdf

11. Tedros Adhanom, et. al. Malaria. in Yemane Berhane, et. al (eds,) Epidemiology and Ecology of

Health and Disease in Ethiopia. Shama books. Addis Ababa. 2006.

12. Ghebreyesus T.A. et. al. incidence of Malaria Among Children Living Near Dams in Northern

Ethiopia: Community-Based Incidence Survey. Br Medical Journal. 319: 663-666. 1999.

13. Afework Hailemariam. Malaria Prevention and Control in Ethiopia. National Malaria Control.

Ethiopia. www.malvacdecision.net/pdfs/Ethiopia%20Overview%20of%20Malaria%20Control.pdf

14. http://www.npr.org/templates/story/story.php?storyId=6463810

15. Gabriel Senay and James Virdin. Developing Malaria Early Warning System in Ethiopia. 25th Annual

ESRI International User Conference. Paper No. UC2409. San Diego. 2005.

16. Sheleme Chibsa. Malaria Vector Control Efforts and Challenges in Ethiopia. 4th WIN meeting, Basel

Switzerland. 2007.